Not just another food program:Integrating Food by Prescription

into HIV care

Elizabeth Jere MPHCORE NACS State of the Art“Getting the Knack of NACS”

Washington DC , February 22-23 2012

Food by Prescription Pilot in Zambia

Timeframe:

Sept 2008 – March 2010

# served: 5360 clients

Sites: 8 ART clinics,

10 hospices , and

2 home-based care programs

Each site had a mature HIV program.

– Embedded routines

– No regular nutrition services

– Large staff

– Little physical space

– Decentralized locations

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Integration Issue #1: Busy clinics, with busy staff.

+ Integration of NACS services into regular routine worked.

+ Some hospices used task-shifting, which had varying success.

- Identifying time for staff training in FBP was challenging.

- Large number of people to be trained.

- Trainings needed to be tailored to reach the different cadres doing same tasks across sites.

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Issue #1 -> Recommendations

Management involvement was a key success factor. • Assess degree of leadership buy-in and supervision

structures.

Explore opportunities for systematizing NACS skills:• Integration into national policies, guidelines and

curricula: IYCN, ART, PMTCT• Pre-service education for (clinical) staff• Integration into HBC and OVC minimum standards,

and care curricula• Incorporate into CME (stagger topics over weeks)• Distance learning certification?

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Integration Issue #2: RUTF and HEPS fall outside the supply chain systems.

- Pilot used a stand-alone system for commodities.

+ Sites improvised storage.

+ Dispensing was managed by different cadres.

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Issue #2: RecommendationsRUTF:

• Integration into government medical stores, similar to F-100/F-75.

• Ensure packaging doesn’t leak.

• How will OVC/HBC/hospice access?

HEPS:

• Not appropriate for government stores?

• Private sector/vouchers? (packaging by dose possible? quality control?)

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Integration Issue #3: Making NACS routine practice

- Assessment was not routine for every client.

- Nutrition counseling was not routine for every client, regardless of nutrition status.

- Standardized M&E forms did not capture important nutrition indicators.

+ FBP services integrated into the decentralized ART services.

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Issue #3: Recommendations

• Get assessment tools into facilities.

• Advocate for nutrition indicators to be in M&E tools.

• Use community programs!

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• “Routine-ize” assessment and counselingfirst, then introduce food

What we wish we knew…

Suggestions for Operations Research

• What is the prevalence of SAM and MAM in HIV-positive adults?

• Do pregnant women need a different eligibility cut-off than non-pregnant women?

• What does it take to make task-shifting successful?

• What in-service training models are most effective to integrate NACS?

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Conclusions Focus NACS service delivery toward

prevention of malnutrition, and less about treatment.

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Conclusions

Approaches need to look at systemization, rather than temporary fixes for time-bound programs.

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Vision:

NACS integrated into nation-wide systems and known to everyone.

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For more information:The CRS Zambia Food by Prescription pilot report:

http://www.crsprogramquality.org/publications/2011/5/19/food-by-prescription-pilot-project-in-zambia.html

The CRS Zambia Food by Prescription pilot summary: http://www.crsprogramquality.org/storage/pubs/hivaids/iacpubs/treatment/Food_by_prescription_low-res.pdf

Guidelines and counseling flip chart (FANTA): http://www.fantaproject.org/publications/zambia_guidelines2011.shtml

Elizabeth Jere, MPHSenior Technical Advisor, STEPS OVC, CRS-Zambia+260 977 400703Elizabeth.Jere@crs.org

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